Provider Demographics
NPI:1356085401
Name:WILLRICH, MARY
Entity Type:Individual
Prefix:
First Name:MARY
Middle Name:
Last Name:WILLRICH
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4135 TIMBER VISTA DR
Mailing Address - Street 2:
Mailing Address - City:BURLESON
Mailing Address - State:TX
Mailing Address - Zip Code:76028-2098
Mailing Address - Country:US
Mailing Address - Phone:817-797-6107
Mailing Address - Fax:
Practice Address - Street 1:4135 TIMBER VISTA DR
Practice Address - Street 2:
Practice Address - City:BURLESON
Practice Address - State:TX
Practice Address - Zip Code:76028-2098
Practice Address - Country:US
Practice Address - Phone:817-797-6107
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-04-25
Last Update Date:2022-04-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes320900000XResidential Treatment FacilitiesCommunity Based Residential Treatment Facility, Intellectual and/or Developmental Disabilities